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HR Forms

Health Benefit Enrollment Forms (Medical, Dental and Vision)
(Please download forms AND open in Adobe Acrobat to complete - All forms are formatted as fillable PDF's and allow an e-signature!)
 
 
 Please use this if you are are enrolling in Blue Shield and/or Delta Dental, and VSP for the 1st time; or changing from Kaiser to Blue Shield coverage
*Please include medical, dental, and/or vision plan number on form. This can be found on rates sheets*
 
This form is used to drop coverage for the employee only
 
 
 Please use this if you are are enrolling in Kaiser and/or Delta Dental, and VSP for the 1st time; or changing from Blue Shield to Kaiser coverage
 
Use this form if you wish to drop a dependent from current coverage, or add a dependent to your current coverage.
 
 
Use this form if you are enrolling on Delta Dental or VSP for the first time
*Please include dental, and/or vision plan number on form. This can be found on rates sheets*
 
(Employees can use this or a recent tax return)
Use this form if you are keeping the same carrier, but changing plans within the same carrier. Example: Changing from Blue Shield Trio to Blue Shield SaveNet
 
 
All new retirees opting to continue coverage with RBUSD/SISC will be asked to complete an enrollment form. If you are a retiree that is changing carriers (i.e. Blue Shield to Kaiser), please also submit the appropriate carrier enrollment form.